What is the appropriate emergency management for a patient with acute left upper extremity weakness and numbness suggestive of an ischemic stroke?

Emergency Management of Acute Left Upper Extremity Weakness and Numbness

Activate emergency medical services immediately and transport directly to the nearest stroke-capable center with CT imaging, as this presentation is acute ischemic stroke until proven otherwise, and every 15-minute delay in treatment increases mortality by 5%. 1, 2

Immediate Prehospital Actions (Target ≤15 Minutes On-Scene)

Time is brain—the single most critical piece of information is determining the exact time the patient was last known to be neurologically normal. 1, 3 This "last known well" time determines all treatment eligibility, not when symptoms were discovered.

On-Scene Assessment and Stabilization

• Assess airway, breathing, and circulation first—intubate only if Glasgow Coma Scale ≤8 or the patient cannot protect their airway. 4, 3
• Check fingerstick glucose immediately—if <60 mg/dL, administer IV dextrose, as hypoglycemia mimics stroke and contraindicates thrombolysis. 4, 1, 3
• Establish IV access with normal saline (avoid dextrose-containing fluids in non-hypoglycemic patients) and draw blood samples for CBC, electrolytes, creatinine, PT/INR, aPTT. 4, 3
• Provide supplemental oxygen only if oxygen saturation <94%—routine oxygen does not improve outcomes. 4, 1, 3
• Do NOT treat blood pressure in the field unless systolic BP ≥220 mmHg, and only after consulting medical command—permissive hypertension maintains cerebral perfusion. 4, 1, 3

Critical Documentation

• Record the exact "last known well" time (when the patient was last observed normal, not when symptoms were discovered). 1, 3
• Document any anticoagulant use (warfarin, direct oral anticoagulants) or recent antiplatelet therapy, as these affect reperfusion eligibility. 3
• Perform a rapid stroke severity assessment using NIHSS or similar validated scale to identify potential large-vessel occlusion. 1, 2, 3

Transport Protocol

Bypass non-stroke hospitals and transport directly to the nearest primary stroke center or comprehensive stroke center. 4, 3 Provide detailed pre-notification including:

• Last known well time 3
• Current neurological deficits and stroke scale score 3
• Vital signs, oxygen saturation, and glucose level 3
• Anticoagulation status 3
• Estimated time of arrival 3

Limit on-scene time to ≤15 minutes—defer non-essential interventions to the transport phase. 3

Hospital Emergency Department Management

Immediate Diagnostic Workup (Door-to-Imaging ≤25 Minutes)

• Non-contrast head CT within 25 minutes of arrival to exclude hemorrhage and identify early ischemic changes. 1, 2
• CT interpretation within 45 minutes for thrombolytic candidates. 1, 2
• Add CT angiography if the patient presents within 6 hours to identify large-vessel occlusion for potential endovascular thrombectomy. 1, 3
• Do NOT delay IV thrombolysis to obtain advanced imaging (perfusion CT or MRI)—rapid treatment supersedes additional imaging. 1

Intravenous Thrombolysis (Door-to-Needle ≤30 Minutes)

Intravenous alteplase 0.9 mg/kg (maximum 90 mg) is the single most beneficial proven intervention for acute ischemic stroke and must be administered within 3-4.5 hours of symptom onset. 4, 1, 5

Pre-Treatment Blood Pressure Requirements

• Reduce BP to <185/110 mmHg BEFORE starting alteplase using labetalol 10 mg IV or nicardipine infusion (starting at 5 mg/h, titrated by 2.5 mg/h every 5-15 minutes, maximum 15 mg/h). 1, 3
• Maintain BP ≤180/105 mmHg during and for 24 hours after alteplase infusion. 1, 3

Dosing Protocol

• 10% of total dose as IV bolus over 1 minute, remaining 90% infused over 60 minutes. 1
• Do NOT administer aspirin within 24 hours of alteplase—this increases hemorrhage risk. 1

Endovascular Thrombectomy (Door-to-Groin ≤90 Minutes)

Consider mechanical thrombectomy with stent retrievers for large-vessel occlusion if all criteria are met: 1, 2

• Pre-stroke modified Rankin Scale 0-1
• Large-vessel occlusion confirmed on CT angiography
• NIHSS ≥6
• ASPECTS ≥6
• Groin puncture possible within 6 hours of symptom onset (up to 24 hours for selected patients meeting advanced imaging criteria)

The "drip-and-ship" model is appropriate—administer IV alteplase at the primary stroke center and immediately transfer for thrombectomy without waiting to assess alteplase effect. 3

Blood Pressure Management (Non-Thrombolysis Candidates)

For patients NOT receiving thrombolysis, practice permissive hypertension unless systolic BP >220 mmHg or diastolic BP >120 mmHg. 1 Aggressive BP lowering may worsen cerebral perfusion to the ischemic penumbra.

• If BP ≥220/120 mmHg, reduce by only 15% during the first 24 hours. 1
• Avoid lowering BP <185/110 mmHg in the acute phase unless thrombolysis is planned. 1

Antiplatelet Therapy

Start aspirin 325 mg within 24-48 hours after stroke onset (or after repeat CT if thrombolysis was given) to reduce early recurrent stroke risk. 1 This timing is Class I, Level A evidence.

• Wait 24 hours after alteplase and obtain repeat head CT to exclude hemorrhage before starting aspirin. 1
• Aspirin is NOT a substitute for IV alteplase in eligible patients. 1
• Clopidogrel alone or dual antiplatelet therapy is NOT recommended for acute ischemic stroke (Class III, Level C). 1

Anticoagulation in the Acute Phase

Do NOT use full-dose unfractionated heparin or low-molecular-weight heparin for acute ischemic stroke—they do not improve outcomes and increase hemorrhage risk (Class III, Level A). 1 Emergency anticoagulation does not lower the risk of early recurrent stroke, even in cardioembolic sources. 1

Hospital Admission and Monitoring

Admit to a dedicated stroke unit with monitored beds for at least 24 hours—stroke unit care reduces mortality and morbidity comparably to the effects of alteplase itself. 4, 1

Supportive Care

• Maintain oxygen saturation ≥94% using pulse oximetry; provide supplemental oxygen only when saturation falls below this threshold. 1
• Check core temperature every 4 hours for the first 48 hours and treat fever promptly (target ≤37.5°C)—fever worsens neurological damage. 1
• Begin intermittent pneumatic compression devices within 24 hours for VTE prophylaxis in immobile patients. 1
• Assess swallowing before any oral intake to prevent aspiration. 1
• Initiate early mobilization within 24 hours (sitting, standing, brief ambulation) if no contraindications exist. 1

Critical Time-Dependent Outcomes

Every 15-minute reduction in door-to-needle time decreases in-hospital mortality by 5%. 1, 3 Every 30-minute delay in reperfusion reduces the probability of favorable outcome by 10.6%. 1

Treatment within 90 minutes of onset is most likely to result in favorable outcomes, with 37% of patients recovering to fully independent function when guidelines are followed. 1

Common Pitfalls to Avoid

• Never delay transport to obtain imaging at a non-CT facility—rapid transport supersedes any on-site intervention without imaging. 3
• Do not withhold treatment for "mild" or improving symptoms—large-vessel occlusions can present with fluctuating deficits. 3
• Never aggressively lower BP in acute stroke unless giving thrombolytics or BP >220/120 mmHg—permissive hypertension maintains penumbral perfusion. 1
• Do not assume patients beyond 4.5 hours are ineligible—endovascular treatment may be offered up to 24 hours with appropriate imaging selection. 3
• Emergency carotid endarterectomy is generally NOT performed for acute ischemic stroke due to high risk of adverse events, especially when the deficit is large. 4